Download RESEARCH ARTICLE Standardized Uptake Values Highly

DOI:http://dx.doi.org/10.7314/APJCP.2014.15.18.7821
PET Standardized Uptake Values Highly Correlate with Tumor Size and Fuhrman Grade in Renal Carcinoma.
RESEARCH ARTICLE
Standardized Uptake Values Highly Correlate with Tumor
Size and Fuhrman Grade in Patients with Clear Cell Renal
Cell Carcinoma
Emre Can Polat1*, Alper Otunctemur2, Emin Ozbek2, Huseyin Besiroglu2, Murat
Dursun2, Kutan Ozer3, Mustafa Ozan Horsanali3
Abstract
Background: We investigated the correlation between standardized uptake value (SUVmax), tumor size and
Fuhrman grade in patients with renal cell carcinoma (RC). Materials and Methods: We retrospectively analyzed
the data of 54 patients with clear cell renal cell carcinoma histopathologically diagnosed who underwent fluorine-18
fluoro-2 deoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) between
January 2005 and March 2014. Results: Avarage tumor sizes were 5.64±1.85, 6.85±2.24 and 7.98±2.45 in low,
medium and high SUVmax groups, respectively. The Spearman’s correlation coefficient between the tumor size
and SUVmax was 0.385 (p=0.004) and between the Fuhrman grade and SUVmax was 0.578 (p<0.001). Conclusions:
SUVmax appears highly correlated with tumor size and Fuhrman grade in patients with histopathologically
confirmed clear cell RC. Multicenter studies are needed to provide larger series for more accurate results.
Keywords: F-18 FDG PET/CT - SUVmax - renal carcinoma - Fuhrman grade - tumor size
Asian Pac J Cancer Prev, 15 (18), 7821-7824
Introduction
Renal cancers account for around 3% of all cancers
(Ferlay et al., 2007) and the most common type (90%) is
renal cell carcinoma (RC) (Motzer et al., 1996). Five-year
survival rate in renal cancer patients is 68.4% all over the
globe (Horner et al., 2010). There has been an increase
in the number of serendipitiously detected renal tumors
in asymptomatic individuals with the widespread use of
conventional imaging modalities including computed
tomography (CT), magnetic resonance imaging (MRI),
and ultrasonography (US) (Jayson and Sanders, 1998;
Luciani et al., 2000). For solid renal masses, presence
of enhancement is the most important criterion for
differentiating malignant lesions (Israel and Bosniak,
2008). Fluorine-18 fluoro-2 deoxyglucose (FDG) positron
emission tomography (PET) has been recognised as
an efficient imaging modality for the management of
oncology patients and has been used increasingly for
primary staging, detection of recurrence, assessment of
residual masses and monitoring therapeutic response in
various types of cancers (Bomanji et al., 2001). Also it
has become an important tool for the detection of bone
metastasis (Liu et al., 2013).
Numerous recent studies of various types of
malignancies have reported an association between the
18-F-FDG accumulation rate evaluated by PET and
patient prognosis. The standardized uptake value (SUV)
is a semiquantitative simplified measurement of the
tissue FDG accumulation rate, and the recent studies of
the head-and-neck, esophagus, lung, and cervical cancer
have explored the prognostic significance of the maximum
standardized uptake value (SUVmax) (Sasaki et al., 2005;
Lee et al., 2009; Ma et al., 2013; Uzel et al., 2013; Zhu
et al., 2013). Although several number of studies have
investigated the usage of PET/CT in the evaluation of
RC, its connection with tumor size and nuclear grade are
not researched enough in literature. We retrospectively
investigated the correlation between SUVmax, tumor size
and Fuhrman grade in patients with histopathologically
shown renal cell carcinoma.
Materials and Methods
We retrospectively analyzed the data of 54 patients
(32 men, 22 women, age range 34-76 years, mean age
53.8±12.4 years) with clear cell renal cell carcinoma
histopathologically who underwent F-18 FDG PET/CT
in Okmeydanı Education and Research Hospital between
January 2005 and March 2014.
The size of the renal masses ranged from 3 to 15
cm, with a mean size of 6.4±3.9 cm. Histologic subtype
Faculty of Medicine, Istanbul Medipol University, 2 Okmeydani Training and Research Hospital, Istanbul, 3Department of
Urology, Faculty of Medicine, Izmir Katip Celebi University, Izmir Ataturk Training and Research Hospital, Izmir, Turkey *For
correspondence: [email protected]
1
Asian Pacific Journal of Cancer Prevention, Vol 15, 2014
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Emre Can Polat et al
was determined according to the 1997 World Health
Organization Heidelberg classification and tumor nuclear
grading was performed according to the Fuhrman
nuclear grading system. PET/CT was carried out using
an integrated PET/CT scanner, which consisted of a
full-ring HI-REZ LSO PET and a six-slice CT (Siemens
Biograph 6; Siemens, Chicago, Illinois, USA). Studies
were performed after at least 6 hours fasting and with the
glucose level lower than 150mg/dl. The CT portion of
the study was carried out without an intravenous contrast
medium, just for defining anatomical landmarks and
making attenuation correction on PET images. CTwas
acquired first with the following parameters: 50mAs,
140 kV, and 5-mm section thickness. Whole-body CT
was performed in a craniocaudal direction. PET images
were acquired in a three-dimensional mode, from the
base of the skull to the midthigh, with five-to-seven bed
positions of 3 min each and PET data were collected in
a caudocranial direction. The CT data were matched and
fused with the PET data. The SUVmax was calculated
using the following formula: SUV=cdc/(d/w), where
cdc is the decay-corrected tracer tissue concentration (in
Bq/g); d, the injected dose (in Bq); and w, the patient’s
body weight (in g).
We divided the tumors into 3 groups according to the
tertile of the SUVmax value, a low group (SUVmax≤2.54),
medium group (2.54<SUVmax≤4.61), and a high group
(SUVmax≥4.61) (Harada et al., 2011). Analyses were
done using Chi-square tests, Kruskal Wallis test and
Mann-Whitney U tests. We also calculated the Spearman’s
correlation coefficient between SUVmax, Fuhrman grade
and tumor size. We considered a p-value<0.05 (two-sided
test) to be a statistically significant difference. All analysis
were conducted using SPSS version 15.0 (SPSS Inc.,
Chicago, Illinois, USA).
Table 2. Relationship between SUVmax and Fuhrman
Grade
Low MediumHigh
SUV
2.54<SUV SUV
max≤2.54 max≤4.61 max≥4.61
No %
No %
No %
Fuhrman grade
Low (1,2)
10.19%
7.13%
High (3,4)
4.7%
9.17%
X29.461
P-value0.009
5.9%
19.35%
*P-value was calculated using the Chi-square test
Table 3. The Spearman’s Correlation Coefficient
between SUVmax, Tumor Size and Fuhrman Grade
SUVmax Tumor Fuhrman
sizegrade
SUVmax
R
1.000
0.385*
p value (two-sided)
0.004
N
54
54
Tumor size
R
0.385*
1.000
p value (two-sided) 0.004
N
54
54
Fuhrman grade R
0.578*
0.479*
p value (two-sided) 0.000
0.000
N
54
54
0.578*
0.000
54
0.479*
0.000
54
1.000
54
*Significant correlation at the level p<0.01. (two-sided)
terms of tumor size (p=0.006) (Table 1). Tumor size and
Fuhrman grade were found significantly higher in the high
SUVmax group (p<0.05).
The Spearman’s correlation coefficient between the
tumor size and SUVmax was 0.385 (p=0.004), indicated
that the tumor size and SUVmax were in moderate
correlation and the Spearman’s correlation coefficient
between the Fuhrman grade and SUVmax was 0.578
(p<0.001), indicating that the Fuhrman grade and
SUVmax were highly correlated (Table 3).
Results
Discussion
Among the 3 tumor groups established according to the
SUVmax values, the tumor size and the Fuhrman grade
were significantly different (Table 1, Table 2). Avarage
tumor sizes were 5.64±1.85, 6.85±2.24 and 7.98±2.45
in low, medium and high SUVmax groups, respectively.
Especially, highly statistical significant difference was
detected between low and high SUVmax groups in
Renal cell carcinoma (RCC-clear cell type) is the most
frequent renal solid tumor. The role of imaging tests is
fundamental for its diagnosis. At present, CT scan is the
most widely employed method to evaluate renal mass,
providing precise information on adjacent and distant
organ involvement (Powles and Ell, 2007; Powles et al.,
2007). MRI and US are alternative imaging modalities
that are also useful, particularly in patients who have
contraindications to contrast-enhanced CT and for the
evaluation of pediatric and pregnant patients given the
lack of radiation dose (Ng et al., 2008).
Wahl et al (1991). first reported the possible value of
18F-FDG PET for the diagnosis of renal cancers in 1991.
The reported sensitivities and specificities of 18F-FDGPET in subsequent studies have generally been suboptimal
in comparison to diagnostic CT or MRI, with sensitivities
ranging from 40%-94% and specificities ranging from
0%-100% (Kocher et al., 1994; Goldberg et al., 1997;
Bachor et al., 1996; Montravers et al., 2000; Ramdave
et al., 2001; Miyakita et al., 2002; Aide et al., 2003;
Kang et al., 2004; Ak and Can, 2005; Kumar et al., 2005;
Martinez et al., 2007). The low sensitivity of 18F-FDG-
Table 1. Relationship between SUVmax and Tumor
Size
Low Medium HighP-value
SUV
2.54<SUV
SUV
max≤2.54 max≤4.61 max≥4.61
No %
No %
No %
Tumor size
5.64±1.85
(cm)
5.64±1.85
5.64±1.85
6.85±2.24
Tumor size ≤7cm 11.20%
(cm)
>7cm3.6%
X28.74
P-value0.013
6.85±2.24
6.85±2.24
7.98±2.45
7.98±2.45
7.13%
9.17%
7.98±2.45 0,019*
0.196
0.006*
0.15
7.13%
17.31%
*P-values were calculated using the Kruskal-Wallis test and Mann-Whitney U tes; p<0.05 was
considered to represent statistical significance
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Asian Pacific Journal of Cancer Prevention, Vol 15, 2014
DOI:http://dx.doi.org/10.7314/APJCP.2014.15.18.7821
PET Standardized Uptake Values Highly Correlate with Tumor Size and Fuhrman Grade in Renal Carcinoma.
PET in some reports has been attributed to FDG excretion
through the kidneys and collecting systems, decreasing
contrast between renal lesions and normal tissues, as well
as due to significant variability of 18F-FDG uptake that
may be related to variable expression of GLUT-1 glucose
transporters, tumor grade, presence of central necrosis,
and/or lack of accessibility of 18F-FDG (Bachor et al.,
1996; Miyauchi et al., 1996; Montravers et al., 2000;
Miyakita et al., 2002; Aide et al., 2003). As we did not
evaluate benign and malignant renal masses other than
clear cell type, we did not calculate the specificity of
18F-FDG-PET/CT.
Khandani et al (Khandani et al., 2012) reported an
avarage SUVmax 3.9 (range1.7-9.5) for clear cell RC and
7.9 (range2.7-13.9) for non-clear cell RC. In our study
although we only anlyze the clear cell subtype, 15 patients
had higher SUVmax values than 7.9 and also 4 patients
had higher SUVmax values than 13.9. Accordingly; we
believe that determination of theavarage. SUVmax value
for renal tumors and its subtypes, larger groups of patients
should be examined.
A few studies have evaluated the influence of
histological and biochemical characteristics of renal
tumours on their visualisation by either FDG PET or other
radiotracers, and their results are discordant. Miyauchi et
al. (Miyauchi et al., 1996) concluded that renal cancers
well visualised by FDG PET had a higher Fuhrman
grade and higher GLUT-1 expression and tended to be
larger than the poorly visualised tumours. In contrast,
Miyakita et al. (Miyakita et al., 2002) found no correlation
between GLUT 1 expression in renal tumours and their
visualisation by FDG PET.
Ozulker et al. (Ozulker et al., 2011) found a significant
correlation between size and FDG uptakes of tumors as
well-visualized tumors were larger than nonvisualized
tumors (p<0.05) and found a relation between Fuhrman
grades of tumors and FDG avidity because the grades
of FDG-positive tumors were significantly higher than
the grades of FDG-negative tumors (p<0.05). In other
studies PET results were not related to Fuhrman score or
histological type of primary tumor. (Majhail et al., 2003;
Nakatani et al., 2009; Bertagna et al., 2013) Nakhoda et
al. (Nakhoda et al., 2013) suggested that 18F-FDG-PET/
CT may be useful to assess RC tumor biology according
to the clear cell RC subtype had significantly greater levels
of metabolism compared to the papillary RC.
Namura et al. (Namura et al., 2010) revealed that the
SUVmax has the potency as a novel biomarker to predict
the survival time of patients with advanced RC and our
findings indicate that high SUVmax values are associated
with bigger tumor size and higher nuclear grade in patients
with clear cell RC.
In conclusion, despite the limitations of our study due
to the retrospective type of evaluation and the absence
of survival analysis, we found an excellent correlation
between SUVmax, tumor size and Fuhrman grade in
patients with histopathologically shown clear cell RC.
We agree the opinion that SUVmax value is a prognostic
factor in RC patients. Additional studies with an expanded
number of patients and period of follow-up are necessary.
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